Treating Spinal Pain: The Value Of Classification ✅ Flashcards
“ Who are we? “
Independent health care professionals that follow the __________________ in order to guide them in their decision-making process.
Evidence
According to the American Physical Therapy Association (APTA), what are we able to do?
Able to independently evaluate, diagnose, and treat patients within the scope of physiotherapy
Meaning we have DIRECT ACCESS
What is the term?
_____________ is to understand how the condition affects the function of the patient.
PT Diagnosis
True or false
Not every patient is a clear case; most patients have a combination of disorders
True
What is meant by differential diagnosis ?
To rule out similar conditions
True or false
Classifications and diagnosis in physical therapy compliment the diagnoses other healthcare professionals make
True
(Not entirely sure what this means)
How do we design the most appropriate treatment plan for the patient?
Ultimate function ?
- What are the levels of classification for LBP (levels I, II, III)
- In level 2 of LBP classification, what are the goals for each stage ?
- Staging the patient in level II of classification is based on what?
- Levels of classification are:
- Level I : if your patient is adequate for PT
- Level II: staging patient
- Level III: assigning patients to treatments - (Answer is in the picture)
Keep in mind: Stage 1 = worse and Stage 3 = better - Based on severity of disability
The key to classification
No structured protocol for every patient = UNIQUE
Key information is identified early in the examination = SKILL
A working hypothesis (classification) is generated and further examinations are performed until a hypothesis is confirmed or disconfirmed = SUBJECTIVE AND OBJECTIVE
What is the term?
_______________________ : ask the questions that we think are the most likely to provide us with the information we need to make a diagnosis.
Subjective assessment
What is the term?
___________________ : tests that we think are the most likely to support or refute the various differential diagnoses
Objective assessment
Just know that after the subjective and objective assessments that some hypotheses become more likely and others less likely, leading us to finally decide which intervention will result in the optimal outcome for the patient .
Got it
Just read
Done
Elements that improve the overall quality of care ?
Evidence-based practice
Clinical expertise
Patient preferences
The treatment approach chosen should be the one the patient MOST likely benefits from
What tool can be used to help ensure this?
Clinical prediction rules (CPRs)
what is the term:
________________________ : tools that guide the clinician in their decision-making process.
Clinical prediction rules (CPRs)
CPRs can be used for _____________, _________________, and _________________
Diagnosis
Prognosis
Intervention / prescription
Majority of CPRs in PT are _________________ in nature.
A. Diagnostic
B. Prescriptive
C. Prognostic
D. Interventional
B. Prescriptive
(Such as prescribing an exercise or technique)
Delitto et all 1995
- What did he propose
- What is it based on
- How many levels of classification
- Proposed a treatment-based classification system
- Based on:
- historical information
- behavior of symptoms
- clinical signs - Three levels of classification
What contributes to a Working Hypothesis ? (Hint: 5)
- history data of the classification
- type and location of symptoms
- Mode of onset
- aggravating and relieving postures (points to mechanical problem)
- number (frequency) and severity of previous episodes
Out of note question:
For spinal pain in general, what do we want to distinguish and how ?
We want to know if this pain is MECHANICAL and NON-MECHANICAL .
Mechanical - pain fades or worsens depending on position/movement
Non-mechanical - pain is consistent no matter the position/movement
True or false
CPRs are mathematical evidence-based tools that are intended to guide physiotherapists in their everyday clinical decision making.
True
Just read
Done
“ with each new piece of the puzzle some hypotheses will become more likely and others less likely “
What is this known as ?
Working hypothesis
Other names for CPRs
Prediction rules
Probability assessments
Prediction models
Decision rules
Risk scores
CPRs should be _____________, _____________, and ___________________.
Created
Validated
Perform an impact analysis
True or false
Prescriptive CPRs are an exponent of the treatment-based system
True
Fill in the classification scheme .
What treatments are involved in level 3 classification STAGE 1 ?
- Specific exercise
- extension
- flexion
- lateral shift - Traction
- Stabilization
- Mobilization
Specific exercise classification (MDT)
Response to repeated end range movements popularized by McKenzie
Centralization (Good/ Green Flag) vs Peripheralization (Bad/ Red Flag)
( avoid movements that cause peripheralization and focus on movements that cause centralization )
Ex: usually flexion causes peripheralization therefore it is avoided for treatment
Keep in mind that Randomized controlled clinical trials (RCTs) found no benefit in heterogeneous samples of patients with LBP so maybe only a subgroup of patients respond to specific exercise.
What is the term?
__________________ : a movement or position results in abolishment of pain or paresthesia or causes migration of symptoms from DISTAL to PROXIMAL locations
Centralization
True or false
Centralization is a bad sign
False
Centralization is a good sign while peripheralization is a bad sign
What is the term?
_____________________ : a situation when movement in one direction improves pain and limitation of ROM and movement in the opposite direction causes signs and symptoms .
Directional preference
Does directional preference mean the same thing as centralization/peripheralization ?
NO. They are NOT the same thing
Patient has back pain 8/10. If he does trunk flexion, it is still 8/10. However, in trunk extension his pain is 4/10.
What is this an example of ?
Directional preference
Traction classification
- criteria according to Delitto
- what did Clark and others say about this treatment
Delitto :
- presence of lower extremity symptoms
- signs of nerve root compression (ex: SLR, Slump)
- absence of centralization with movement testing
Clark:
Traction intervention is NOT recommended
(Lack of evidence that supports traction)
Stabilization classification
- when is it used ?
- what was the treatment before the focus was shifted to stabilization ?
Hypermobility , excessive segmental movements
Before, treatment for hypermobility was usually IMMOBILIZATION (such as wearing a brace for ex: TLSO). But now research shifted the focus to STABILIZATION
Who are considered good candidates for stabilization ?
(What’s the criteria / Hint: 7)
- Patient history (that points to hypermobility)
- Frequent recurrences / minimal perturbation
- Alternating sides of lateral shifts
- Frequent manipulations with short relief (self/practitioner)
- Trauma
- Pregnancy , oral contraceptive use (due to hormone effect/ laxity)
- Support device is useful (causes relief)
What can we see in the physical examination that points to hypermobility and the need for stabilization ?
(Hint: 7)
- general ligament laxity (Beighton Score)
- instability catch on forward bending
- painful arc on return from forward bending
- reversal of lumbo-pelvic rhythm
- thigh climbing
- positive posterior shear test (PPPP, Thigh thrust)
- spine hyperextension (lordotic posture)
True or false
Beighton score tests for hypomobility
False
Hypermobility
Beighton Score
- what does it test for?
- What are the steps/items ?
- Score interpretation ?
It is for HYPERMOBILITY
- Touch floor without bending knees (extended elbows with hands flat on floor) = 1 point
- Extend knee = 1 point each leg
- Extend elbow = 1 point each arm
- Extend pinky beyond 90 ° = 1 point each hand
- Bend thumb to forearm = 1 point each hand
Score is out of /9
- A score of 4/9 or above may indicate GENERAL hypermobility
True or false
Although stabilization treatment focuses on exercises that enhance the stabilization capacity of spinal muscles, Stabilization exercises may only be effective for a subgroup of LBP patients
True
Because not all LBP meet the criteria for stabilization treatment ( meaning not all LBP patients suffer from hypermobility )
Hicks et al, 2005
- what did he do?
- who were the participants of his study?
- Describe the exercise program used .
- What has he identified ?
He developed a CPR to predict treatment response to a stabilization exercise program for patients with LBP
(Preliminary Stablilization CPR)
54 patients with non-radicular LBP ( LBP not associated with neural issues)
8 weeks of stabilization training of:
- multifidus
- erector spinae
- transversus abdominis
- oblique abdominals
He has identified 4 FACTORS/PREDICTORS
- Age < 40 years
- SLR > 91 °
- Aberrant movements during sagittal plane lumbar ROM
- Positive prone instability test
Preliminary Stabilization CPR
- who contributed to this rule?
- what are the predictors ?
- probability of success requires how many of these predictors to be present ?
Hicks (et al) 2005
- Age < 40 years
- SLR > 91 ° (Normal 80-90 °)
- Aberrant (abnormal) movements during sagittal plane lumbar ROM
- Positive prone instability test
If 3/4 of these factors are present = success rate increases from 50% to 80%
Management of hypermobility in the past vs present
Past:
- avoid end range movements
- bracing (immobilization)
- spinal muscle strengthening
Present:
- retraining of deep spinal muscles (stabilization of core)
- strengthening large muscles of spine (global muscles)
Mobilization/ Manipulation Classification
- what is it used for?
- contraindicated in patients with what?
- its effectiveness ?
Used for Hypomobility
Contraindicated for Hypermobility (could cause serious harm)
Only effective for a subgroup of LBP
Flynn et all, 2002
- what did he develop?
- participants?
- predictors/factors ?
- how many factors should be present to increase probability of success ?
Developed a CPR for identifying patients with LBP who improve with spinal mobilization (Mobilization CPR)
71 patients with non-radicular LBP
- Current symptoms less than 16 days (symptom duration)
- FABQ-W less than 19 ( fear avoidance belief questionnaire)
- Hypomobility in lumbar spine (PA pressure)
- Internal rotation ROM at least one hip greater than 35 °
- Symptoms not distal to the knee
4/5 factors present = increases success from 50% to 95%
Mobilization CPR
- who contributed to it?
- what are the factors ?
Flynn 2002
- Current symptoms less than 16 days (symptom duration)
- FABQ-W less than 19 ( fear avoidance belief questionnaire)
- Hypomobility in lumbar spine (PA pressure)
- Internal rotation ROM at least one hip greater than 35 °
- Symptoms not distal to the knee
Red flags for manipulation (contraindications / Hint: 10 )
Patient has SLR< 45 ° , reduced LL strength and reduced sensation or reflexes, hinting at nerve root compression with radicular pattern
Can we do manipulation ?
NO. It is contraindicated
Patient has done lumbar/sacral spine surgery.
Can we do manipulation?
NO. It is contraindicated
Patient is pregnant
Can we do spinal manipulation?
NO. It is contraindicated
Patient suffered spinal fractures.
Can we do manipulation?
NO. It is contraindicated
Patient has metastatic cancer
Can we do manipulation?
NO. It is contraindicated
Patient has sexual dysfunction
Can we do manipulation?
NO. It is contraindicated
Patient has generalized weakness
Can we do manipulation?
NO. It is contraindicated
Patient has severe night pain that is not related to position (non-mechanical pain)
Can we do manipulation?
NO. It is contraindicated
Patient has bowel or bladder dysfunction such as urinary/fecal incontinence, rectal bleeding, or hematuria
Can we do manipulation?
NO. It is contraindicated
Patient has saddle paresthesia (regarding the S4 dermatome area)
Can we do manipulation?
NO. It is contraindicated
Patient has pain that centralizes with two or more movements in the same direction (ex: extension) but peripheralizes with a movement in the opposite direction
Which classification will suit the patient ?
Specific exercise classification
Patient’s symptoms started less than 16 days ago. None of these symptoms are experienced distal to the knee. These symptoms do not centralize in a certain direction. Hypomobility was found.
Which classification suits the patient
Manipulation classification
27 year old patient has SLR > 91 ° .
Prone instability test was positive .
(Or aberrant movements were observed)
Which classification suits the patient
Stabilization classification
Because these are indicators of hypermobility
All of the following factors favor which treatment program?
- More recent onset of symptoms
- hypomobility with spring testing
- LBP only (no distal symptoms)
- FABQW < 19
Manipulation / Mobilization
All of the following factors favor which treatment plan?
- younger age
- Positive prone instability test
- aberrant motions
- Greater SLR ROM
- hypermobility with spring testing
- increasing episode frequency
- Three or more prior episodes
Stabilization
All of the following factors favor which treatment plan?
- strong preference for sitting or walking
- centralization with motion testing
- Peripheralization in direction opposite centralization
Specific exercise
All of the following factors are against which treatment plan ?
- symptoms below the knee
- increasing episode frequency
- Peripheralization with motion testing
- No pain with spring testing
Manipulation / mobilization
All of the following factors are against which treatment plan ?
- discrepancy in SLR ROM (<10 °)
- FABQPA < 9
Stabilization
All of the following factors are against which treatment plan ?
- Low back pain only (no distal symptoms)
- status quo with all movements (symptoms don’t change with specific movements / no centralization or peripheralization)
Specific exercise
Keep in mind: cervical spine and thoracic spine are connected to each other so it’s normal to treat the thoracic spine and witness symptoms regarding the cervical spine disappear or lessen as a result .
Why?
Because T/S mobility problems contribute to neck disorders and neck pain
Also there are lesser risks with T/S manipulation than with C/S manipulation
(Neck Pain)
Cleland 2007
- what CPR did he contribute to?
- what are the factors ? ( hint: 6 )
- how many factors must be present to increase the probability of success ?
Preliminary T/S manipulation CPR
- Symptom duration < 30 days
- No symptoms distal to the shoulder.
- Looking up does not aggravate symptoms (flexion is painful but extension is not)
- FABQ-PA < 12
- Diminished upper T/S kyphosis (T3 - T5)
- C/S extension < 30 °
3/6 present = success increases from 54% to 86%
4/6 present = success increases from 54% to 93%
True or false
Clinical experience suggests that THORACIC spine thrust procedure (manipulation) maybe useful for NECK pain
True
True or false
There is a lower risk with T/S manipulation than with C/S manipulation
True
(Neck pain)
Raney 2009
- what CPR did he contribute to?
- What are the factors? (Hint: 5)
- How many factors should be present see an increase in the probability of success?
Preliminary C/S traction CPR
- Peripheralization with lower C/S (C4-C7) mobility testing
- Positive shoulder abduction test
- Age ≥ 55
- Positive upper limb tension test
- Positive neck distraction test
3/5 present = success increases from 44% to 79%
4/5 present = success increases to 94.8%
Who contributed to the preliminary C/S traction CPR?
Raney 2009
True or false
C/S traction is used frequently for neck pain
True
True or false
Traction is appropriate for neck AND upper extremity symptoms and signs of neurological compromise
True
True or false
Traction is a good treatment option for nerve root compression in the cervical spine
True
(Neck pain)
Tseng 2006
- what CPR did he contribute to?
- What are the factors? ( hint: 6)
- How many factors should be present see an increase in the probability of success?
C/S manipulation CPR
- Neck disability index NDI < 11.5
- Bilateral involvement pattern
- Not performing sedentary work > 5hrs/day
- Feeling better while moving neck.
- Neck extension doesn’t worsen symptoms
- Diagnosis of spondylosis without radiculopathy.
4/6 present = success increases from 60% to 89%
Who contributed to C/S manipulation CPR
Tseng 2006
Do we have CPR’s for thoracic pain?
According to the note, there has been limited research
